Insights into healthcare public managers’ compensation: Influential factors and sustainable financing solutions: A scoping review

Abstract

Transparent and fair compensation standards for managers are crucial across various sectors, with particular attention needed in the public and non-profit realms, notably within healthcare settings. Despite the extensive focus on equitable compensation in the private sector, the public and non-profit sectors have not received commensurate attention in this regard. Using Arkesy and O’Malley’s framework, a scoping review conducted in June 2024 aimed to identify compensation criteria and sustainable financing solutions for these sectors. Required data were gathered from international databases such as PubMed, Web of Science, and Scopus, as well as Iranian databases including MagIran, IranMedex, and SID. Thirty-four relevant studies were included out of 8329 initially screened Most of the studies (25 studies) were conducted in the United States. Through content analysis, these studies revealed 107 subcriteria, amalgamating into 22 main criteria, further categorized into seven thematic groups. Despite the variety of the identified criteria, only one sustainable financing solution was identified, which was the compensation of managers in not-for-profit organizations under the 990 Form of the Internal Revenue Service (IRS) through Act 330 of the Public Health Act. The prioritization of economic and accounting criteria in the identified studies reflects trends observed in the for-profit sector. However, it is imperative not to overlook the significance of social criteria, given the public sector’s inherent social responsibilities. Policymakers and researchers are urged to ensure stable resource allocation to mitigate potential financial crises.

Introduction

The compensation of public managers and its connection with organizational performance has stirred debate in management, economics, and finance.[1] Senior managers’ compensation methods and amounts have drawn public attention, particularly in Europe and the United States.[2,3,4,5,6,7]

Managers, whether in leadership or implementation roles, are pivotal for organizational vitality. Thus, enhancing their motivation and loyalty through appropriate compensation strategies is crucial. However, evaluating managerial pay’s adequacy poses challenges, raising questions about its alignment with organizational success. This dilemma prompts researchers to explore the relationship between managerial compensation, especially for senior executives, and organizational performance.[4,8] Studies have shown a significant positive correlation between incentive-based payments and improved organizational performance.[9,10] Conversely, Hall and Murphy (2003) found that until 2002, senior executives’ total cash payments were substantially higher than those of average manufacturing workers, highlighting disparities in compensation.[11] Thus, establishing fair compensation plans that align with performance is essential.

The lack of evidence-based decision-making, often due to inadequate information systems, results in subjective evaluations and unfair compensation for managers. Government expansion and bureaucratic structures further compound this issue, leading to unjust compensation. In developing countries, managerial selection and compensation are influenced by proximity to power and resource access. While many studies have examined payment systems in private companies in healthcare and beyond[12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27] and senior managers’ roles in public institutions,[28,29] there is still a gap in understanding compensation specifically in public and non-profit sectors, especially in healthcare.[27] In addition, public and not-for-profit sectors generally provide critical healthcare services to underserved populations. In order to increase the competitiveness, these sectors should offer higher levels of incentives compared with their private counterparts. Therefore, they greatly rely on sustainable financing, especially in terms of timely and sufficient compensation plans to survive in the unbalanced quarrel for “better payments.”[27,28] To encapsulate, a scoping review was conducted to identify compensation criteria and sustainable financing solutions for these sectors.

Materials and Method

The current study is a scoping review, a type of systematic review study. We utilized the Arkesy and O’Malley framework, which is recognized as one of the most comprehensive frameworks for systematic reviews. This framework consists of six steps: (a) “Identification of the research question,” (b) “Identification of relevant studies,” (c) “Study selection,” (d) “Data charting,” (e) “Data analysis and reporting the results,” and (f) “Consultation exercise” for providing practical guidance and recommendations.[30]

A) Identification of the research question

The main research questions of the present study, formulated using the opinions of the research team members and primary literature review, are as follows:

• “What are the influential factors of public and not-for-profit managers’ compensation?”

• “What are the existing sustainable financing approaches?”

Inclusion/exclusion criteria

In line with the study’s aim to investigate the criteria and financing methods for public and non-profit managers, it was imperative to delineate the private sector from the public and non-profit sectors by using appropriate and scientific criteria. To achieve this, the review study conducted by Jan van Helden and Christoph Reichard (2016)[31] was consulted as a basis for establishing inclusion and exclusion criteria. The following table [Table 1] outlines the inclusion and exclusion criteria for the studies extracted during the scoping review stage.

Table 1.

Inclusion and exclusion criteria

Exclusion

Inclusion

•Studies that were conducted in public or government organizations and institutions, as well as non-profit organizations, especially in health settings, including: Public, government, and military institutions, including officials and staff managers at different levels in government ministries, public and government organizations, and charitable institutions (non-private and family) •The studies that focused on the total compensation, incentive payments, bonuses, or any other related variable payments to the managers of the aforementioned organizations at different levels in government ministries, public and government organizations, and charitable institutions (non-private and family) •Studies that focused on the financing of these payments to managers •Only published articles, books, reports and theses were included.

•Organizations, companies, private institutions, and any other entity whose primary purpose was to gain profit from the sale of services or goods or to maximize it (regardless of the type of ownership), were excluded from the study. To ensure a precise distinction and remove ambiguity in our decision to include or exclude studies, we took the following steps: a) We referred to more information available in the study. b) We conducted further research on the nature of the organizations (searching about the nature of the discussed institutions on the Internet and the websites of those institutions, and emailing the authors of the articles). c) If ambiguity persisted or further investigation was required, we consulted among the members of the research team and made a final decision, taking into account the established model. •According to the presented model (31), control over public institutions is exercised at different levels and by multiple stakeholders with mainly divergent motives, and it is not owned by an individual or family members. Therefore, studies focusing solely on private and family-owned non-profit organizations, including private non-profit organizations, private charities, and family-owned non-profit charities, were not included in the study. •Studies done in non-managerial environment. •Studies in any other languages than English and Persian. •The studies that lacked effective or significant relationship between manager (s) compensation and the affecting factors

B) Identification of relevant studies

The Web of Science, Scopus, and PubMed databases were searched using relevant keywords until September 12, 2023 (refer to Appendix 1). In addition, Persian databases, including, Magiran, IranMedex, and SID, were investigated using the Persian equivalents of the keywords utilized. The keywords included:

• Manager, Executive, Managerial, Officials, President, Chairman, Senior manager, CEO

• Compensation, Compensation plan, Compensation design, Pay, Bonus, Variable payment, Incentive, Reimbursement, Benefit, Fringe benefits/perquisites, Gratuity

In the manual search phase of articles, both the Google and Google Scholar search engines were queried using the designated keywords. In addition, websites of international organizations such as the United Nations (UN), World Health Organization (WHO), World Bank Group (WBG), International Monetary Fund (IMF), Organization for Economic Cooperation and Development (OECD), and OECD Library, as well as selected government websites, such as UK government, United States Department of Health and Human Services (DHSS), and Turkish government website, were thoroughly examined using the aforementioned keywords. Furthermore, the reference check method (reference by reference) was employed to identify related articles and sources. The results of this stage encompassed articles from various databases, booklets, and guidelines from diverse organizations worldwide, along with published government documents, all of which were included in the study for further examination.

C) Study selection

All stages of selection and screening of articles were independently conducted by two members of the research team. Disputed matters were resolved through discussion, and if necessary, referred to a third person with more information and experience. Initially, all article titles and documents were reviewed, and articles that did not align with the study objectives were excluded. Subsequently, the abstracts and full texts of the articles were examined to identify and exclude studies that met the exclusion criteria or were weakly related to the study objectives. Endnote 21 resource management software was utilized to organize and study titles and abstracts, as well as to identify duplicates. The PRISMA flowchart[32,33] was employed to report the results of the selection and screening process.

D) Data charting

The data extraction form was designed using Word 2019 software. The form consisted of general information about the selected studies, such as the study’s purpose, author name, publication year, country of study, criteria used in paying public and not-for-profit managers, subcriteria or how these criteria influenced, and financing solutions. Initially, the data from five articles were extracted as a pilot phase, and any defects or problems in the initial form were addressed. Data extraction was performed by one member of the research team and verified by a second person. Any ambiguous items were resolved by consulting other members of the research team.

E) Data analysis and reporting the results

After data extraction, the information was manually analyzed, summarized, and reported using the content analysis method. Content analysis is a method used to identify, analyze, and report patterns (themes) in the text and is widely employed in qualitative data analysis.[34,35,36,37] Data coding was independently conducted by two researchers.

F) Consultation exercise

After extracting and reporting the results, guidance and recommendations were formulated based on the extracted results and the opinions of the research team members. These were presented in the form of article discussions and suggestions.

Results

Figure 1 presents the PRISMA (2022) flow diagram depicting the systematic review process. Initially, 8200 studies were identified, with 1829 duplicates removed. Subsequently, 5742 studies were excluded based on title and abstract review. Of the remaining 370 studies, 20 were excluded due to inaccessible full text. During the gray literature review, 129 additional studies were retrieved. After reviewing the full texts, 445 studies were excluded, leaving 34 for final analysis. Details of the extracted information from these studies are available in Appendix 2.

Figure 1.

PRISMA flow diagram

The results are presented in four sections: the time distribution of studies, identified themes, financing approaches for public and non-profit managers’ compensation, and thematic classification of study objectives.

Time distribution of studies

Spanning from 1993 to 2022, the studies showed a peak frequency (14 studies) between 2010 and 2015, as depicted in Figure 2. Over time, there was an increasing trend in studies, divided into 5-year periods. The majority of studies[25] originated from the United States, followed by nine studies from OECD member countries such as Canada, Brazil, and Iran.

Figure 2.

Frequency of studies based on the year of publication

Classification of studies objectives

Table 2 illustrates the subject classification of study objectives across various sectors, including higher education, health, municipalities, city management, or a combination of public or non-profit organizations.

Table 2.

Subject classification of study objectives

Class	Title	Healthcare	Higher education	Municipalities and city management	Other NFPs and public organizations
1	Performance and compensation	2	1	-	2
2	Influential factors in manager’s compensation	4	4	2	12
3	Board members, shareholders, and supervisors in determining managers’ compensation	-	-	-	3
4	Gender in managerial compensation	1	1	-	-
5	Others	-	-	-	2

According to Table 2, the objectives of the studies were categorized into five groups. The first group comprised studies aiming to measure the association between different forms of performance, such as clinical and economic metrics and managers’ compensation across different hierarchical levels. The second group encompassed studies that identified case criteria or a set of organizational, non-organizational, financial, economic, or individual factors influencing managers’ compensation, which were the most prevalent with a total of 22 studies. The third group investigated the role of board members, shareholders, and supervisors in determining managers’ compensation, focusing on changes in the amount received or adherence to regulatory frameworks. The fourth group directly assessed the relationship between gender and managers’ compensation. Finally, two studies with other objectives, including “investigating the impact of replacing the new meritocratic evaluation system for managers with the old system based on individual judgments” and “providing a definition of rewards for senior government officials,” constituted the fifth group.

Influential factors in public and non-profit managers’ compensation

Figure 3 illustrates a total of 107 criteria identified from the studies, with a cumulative frequency of 137. These criteria were classified into seven groups and 22 subgroups. The first group, comprising four subgroups and 28 criteria (with a frequency of 44), ranked highest among the other groups. For further details on classification and the impact of each criterion on manager compensation, please refer to Appendix 3.

Figure 3.

Categorization of groups, subgroups, criteria and their frequency

1. Economic, Financial, and Accounting Performance Components

This group was divided into four subgroups: Economic Ratios and Accounting Components, Government grants, Public grants and contributions, and Other Economic Components. Among the seven groups, this group had the most criteria, totaling 28 criteria with a frequency of 44 repetitions. In addition, the subgroup Economic Ratios and Accounting Components had the highest frequency of extracted criteria within the first group, with a total of 17 criteria and a frequency of 27 repetitions.

Specifically, “efficiency,” “program ratio,” “profit,” and “return on investment (ROI)” were the highly frequent categories within this group. In addition, 12 further criteria, including “equity ratio index,” “full-time equivalent (FTE) of manager,” “income per student,” “lagged commercial revenue,” “investment portfolio to total assets,” “income from Medicare and Medicaid,” “share of temporary restricted net assets,” “total assets of the organization,” “total sales value,” “number of clients, customers, or patients,” and finally, “three-year cohort default rate (TCDR)” were identified.[38,39,40,41,42,43,44,45,46,47,48,49,50] In addition, five criteria of the subgroup of government grants included “the amount of allocated budget to the organization,” “government grants,” “increase in the share of government grants” (which reflects the manager’s ability to attract government assistance and credits), and “the dedication and the amount of government grants.[38,44,45,48]” Furthermore, “public indirect support” and a combination of the three components of “government grants,” “direct” and “indirect non-governmental public support” together formed the subgroup of public support.[44,45,48]

Finally, eight criteria were identified as other effective economic criteria, including “the manager’s budgetary performance,” “tax performance,” “relative performance of city managers,” “contracted or direct service delivery (adjusted by the number of under-cover population),” “ratio of federal and state grants to total revenue,” “endowment or donation to the organization,” “payments to affiliates,” and “contracted managed hospitals.”[44,51,52,53,54]

2. Organizational and Intra-organizational Components

This group was divided into four subgroups: the “size and “complexity” of the organization, the “type” of organization, “the income of other managers and employees within the organization,” and “other” organizational components. With 27 criteria and 32 components, this group ranked second among the seven groups. In addition, the subgroup of “size and complexity” of the organization, with 12 criteria and frequency of 16, was the most frequent subgroup.

Criteria of “organization size,” “number of employees,” “number of acute hospital beds,” “multi-sited hospital,” “total assets annually,” “total deferred fixed assets,” “total assets, total expenses,” “number of employees with income below USD 50,000,” “number of staffed hospital beds,” “number of services per full-time employee,” “organization’s income elasticity,” and “number of income sources” formed the subgroup of “size and complexity.”[42,43,44,45,47,54,55,56,57] Consequently, “the ministry of occupation,” “indirect administration,” (an organization with non-governmental ownership but with a governmental function), “system affiliation” (the manager is socially and politically linked to political and social institutions), and in the case of hospitals, “educational reference compared to only educational,” “educational hospital,” and “having academic affiliation,” formed the “organization type” subgroup.[49,54,55,57,58] In addition, “the income level of employees with the highest income in the organization” and “the average salary for assistant professors of all disciplines in a university” were two effective components in “the income of other managers and employees within the organization” subgroup.[38,39]

As for the other effective criteria in this group, “result-based evaluation of performance mechanism,” “internal promotion versus external hiring,” “the difficulty of work in terms of the number of sites under the manager’s supervision,” multiple international university ranking systems,” that is, U.S. News and World Report college rankings, “Carnegie classification,” “other international ranking systems,” and “the number of university entries” were identified.[38,50,59,60,61]

3. Environmental and Extra-organizational Factors

The environmental and extra-organizational factors group, ranking third among the seven groups, comprises 19 criteria with a frequency of 22. This group encompasses five subgroups: the location of the organization, including hospital location in the city and university density of the surrounding area[50,54,56]; per capita income of the manager’s place of residence[42,44]; rival managers’ compensation, involving three qualitative criteria of representativeness, alimentation, and market, and the average annual income of parliament members[62,63,64]; legislative requirements, such as legal ceiling for managers’ remuneration[42]; and other extra-organizational components, such as city’s population size, percentage of non-white people in the city, CEO’s income level, type of industry, private donors, ideology (Christianity religious beliefs), Kaufman’s three indicators of freedom and democracy (including “voice and accountability,” “rule of law,” and “control corruption”), and finally, the efficacy of the government, which was divided into “government effectiveness” and “regulatory quality.”[51,57,63,64,65,66,67]

4. Personality and Demographic Characteristics

This group comprises four subgroups: gender, experience, education, and other personality components of managers. With 12 subcriteria and a frequency of 19 repetitions, it ranks fourth among the seven groups. Gender differences were explored in five studies, where being male increased compensation in four studies and decreased it in one study. In addition, improving the international ranking of the university reduced this gender difference in one study.[38,48,54,56,61] The subgroup of management experience includes criteria such as the number of years the manager has worked in the same organization, seniority, and number of previous positions, all with a positive effect. The city population also played a mediating role. If the city manager was leading a city with under 50 thousand people, then the number of cities they had previously led had a negative effect on their compensation in relation to experience. Conversely, if the manager was leading a city of over 50,000 people, the number of previous cities they had led had a positive effect. The education subgroup comprises criteria such as having a medical education compared to non-medical education, duration and level of education, and holding an MBA degree, all with a positive effect.[38,49,56,68] Other personality components include managerial responsibility, managerial level, ethnicity, performance-based payment scheme for managers, and senior manager’s age.[38,49,68,69]

5. Executive Board

This group ranks fifth overall, comprising 12 criteria with a frequency of 13 repetitions. Within the subgroup of functional characteristics, five criteria were identified, including transparency in board members’ roles and duties, clear oversight of payments, reasonable performance standards, board member independence, and efficient payment monitoring processes, each with varying effects based on conditions.[70] The subgroup of board size encompasses two criteria: the count of paid and unpaid directors. Furthermore, the subgroup of board structure includes five criteria, such as the total number of non-senior managers on the board, the percentage of internal managers on the board, the percentage of directors with political ties, the percentage of external directors appointed by the CEO, and the CEO’s tenure as a board member, all positively impacting the CEO’s earnings.[45,71]

6. Politics

The subgroup of politics consists of five criteria, including, ”exogenous termination risk,” “patronage in government appointments,” “political sensitivity,” “political networking,” and “institutional pressure”. This group ranks sixth with five criteria and a frequency of five repetitions.[69,72,73]

7. Quality

This group ranked seventh with two criteria: the quality of staff performance and recommending hospital services to others by patients, with a frequency of two repetitions in studies.[46,68]

Financing solutions

Only one study had attempted to provide a solution for financing payments to managers. The study by Davlyatov et al. (2019)[38] aimed to measure the relationship between the clinical performance of not-for-profit community health centers and the payment to the chief executive officer. They identified Act 330 of the Public Health Act for the not-for-profit organizations under the 990 Form of the Internal Revenue Service (IRS) as a source of managers’ compensation.

Discussion

The analysis of 34 studies (comprising articles, reports, documents, and guidelines) revealed that the period between 2010 and 2015 had the highest frequency, with 14 cases. The majority of studies originated from the United States, totaling 25 studies. Overall, the research identified seven main groups, encompassing 22 subgroups and a total of 107 criteria.

The lack of sustainable funding for compensating managers is a notable finding, with only one study suggesting solutions.[38] Unlike private institutions, public and non-profit organizations struggle to allocate financial resources for managerial compensation due to socio-political factors and funding stability issues. This can impact managers’ motivation and lead to subjective compensation decisions, potentially affecting organizational performance.

Gender emerged as a key factor influencing managerial compensation, especially at senior levels, with male managers generally receiving higher pay than female counterparts. This highlights gender disparities and prompts discussions on concepts such as the glass ceiling and the glass cliff, revealing gender-based challenges. Researchers noted gender discrimination as a prevalent issue affecting managerial pay, emphasizing the need to promote equal pay for equal work. This calls for establishing a fair evaluation system prioritizing performance outcomes over gender biases.[28]

The primary focus in the first group centered on “Economic, Financial, and Accounting Performance Components.” This highlights a tendency among decision-makers and governments to prioritize managers’ financial and economic performance, even in public and non-profit organizations, often overlooking social responsibilities. However, this exclusive focus on economic metrics may undermine the broader societal objectives of these organizations, primarily aimed at serving public and non-profit goals. Thus, there is a need for evaluation systems to consider not only economic performance but also comprehensive criteria assessing the organization’s social impact. This balanced approach would ensure assessments reflect both economic viability and social value creation, including aspects such as service quality, equitable access, and responsiveness to vulnerable populations.

The findings highlighted the significant influence of managers’ perceptions within the organization or the broader labor market on compensation strategies in public organizations. O’Toole and Mayer’s study underscored the widespread use of benchmarking and market comparisons by government entities and managers to determine compensation levels. When managers in similar roles across industries receive higher compensation, it pressures public sector organizations to align their compensation to attract and retain talent. This fosters healthy competition and helps mitigate the risk of talent migration to other sectors.[74]

Elevating the ranking of universities in international systems significantly influenced the recognition and compensation of presidents in public universities but not necessarily in private institutions. Public universities, reliant on government funding, saw increased financial support with higher rankings, allowing for higher executive salaries. Private universities, funded differently, saw less impact on compensation. Thus, ranking upgrades may affect public university presidents more than private counterparts.[75]

Setting a payment ceiling for managers, especially senior executives in public and non-profit organizations, requires considering factors such as organizational size. Surprisingly, implementing payment regulations increased costs by 6.3%, attributed to higher payments to senior executives. Smaller non-profits in California were disproportionately affected due to administrative burdens, leading to earlier cost increases.[42]

Politics often positively influences manager compensation, especially in public and government organizations. This influence, prevalent in both developed and developing nations, is more pronounced in developing countries due to information infrastructure deficiencies. Addressing this requires ensuring governance institution independence, promoting transparency, and transitioning to merit-based evaluation systems to reduce political influence on compensation.[76]

The main limitations were the restricted access to information and experiences from various countries. This limitation may stem from factors such as the non-disclosure of countries’ programs and policies or their publication in languages other than English or Persian, thereby limiting the study’s scope and depth.

Conclusion

Results revealed economic factors as primary determinants of compensation, mirroring the private sector. However, societal obligations necessitate consideration of social criteria alongside economic performance. The study highlighted a lack of sustainable financing solutions, emphasizing the need for policymakers to ensure stable resources and proactive research to prevent financial crises. Therefore, future research can investigate the integration of social responsibility indices, such as community engagement and health equity, into compensation frameworks to align incentives with broader societal goals.

Conflicts of interest

There are no conflicts of interest.

Appendix 1. Search strategies in databases

Database	SET	search strategy	Result
PubMed	#1	((((((((((((((((Compensation[Title]) OR (“Compensation plan”[Title])) OR (“Compensation design”[Title])) OR (Pay[Title])) OR (Bonus[Title])) OR (“Variable payment”[Title])) OR (Incentive[Title])) OR (Reimbursement[Title])) OR (Benefit[Title])) OR (“Fringe benefits”[Title])) OR (“Fringe perquisites”[Title])) OR (Gratuity[Title])) OR (Remuneration[Title])) OR (Fee[Title])) OR (Stipend[Title])) OR (Emolument[Title])) OR (“Merit pays”[Title])	67441
	#2	(((((((CEO[Title]) OR (manger[Title])) OR (Executive[Title])) OR (Managerial[Title])) OR (Officials[Title])) OR (President[Title])) OR (chairman[Title])) OR (“Senior manager”[Title])	30874
	#3	#1 AND #2	270
Scopus	#1	Title: (TITLE (compensation) OR TITLE (“Compensation plan”) OR TITLE (“Compensation design”) OR TITLE (pay) OR TITLE (bonus) OR TITLE (“Variable payment”) OR TITLE (incentive) OR TITLE (reimbursement) OR TITLE (benefit) OR TITLE (“Fringe benefits”) OR TITLE (“Fringe prequisites”) OR TITLE (gratuity) OR TITLE (remuneration) OR TITLE (fee) OR TITLE (stipend) OR TITLE (emolument) OR TITLE (“Merit pays”))	349258
	#2	Title: (TITLE (ceo) OR TITLE (manager) OR TITLE (executive) OR TITLE (managerial) OR TITLE (officials) OR TITLE (president) OR TITLE (chairman) OR TITLE (“Senior manager”))	102598
	#3	#1 AND #2	4999
Web of Science	#1	TI=(Compensation) OR TI=(“Compensation design”) OR TI=(“Compensation plan”) OR TI=(Pay) OR TI=(Bonus) OR TI=(“Variable payment”) OR TI=(Incentive) OR TI=(Reimbursement) OR TI=(Benefit) OR TI=(“Fringe benefits”) OR TI=(“Fringe perquisites”) OR TI=(Gratuity) OR TI=(Remuneration) OR TI=(Fee) OR TI=(Stipend) OR TI=(Emolument) OR TI=(“Merit pay”)	227124
	#2	TI=(CEO) OR TI=(manger) OR TI=(Executive) OR TI=(Managerial) OR TI=(Officials) OR TI=(President) OR TI=(chairman) OR TI=(“Senior manager”)	72392
	#3	#1 AND #2	2931

Appendix 2. Extraction Table

Appendix 3. Categorization Manual

Groups	Sub-groups	Criteria in the studies			Impact on manager’s compensation (positive/ negative/ variable)
Economic, Financial, and Accounting Performance Components	Economic Ratios and Accounting Components	Efficiency	Administrative efficiency or the ratio of administrative costs to total costs		+
			Savings indicator as an indicator for efficiency in non-profit hospitals		+
			Administrative efficiency ratio		+
			Technical efficiency ratio		+
		Program ratio	Ratio of project-related costs to total costs		-
			Service cost related to programs		+
			Payment for project costs		+
			Related service cost to programs		+
		Profit	Total profit of the institution		+
			Total profit in terms of quality		+
			Operating margin		+
			Profitability of the hospital		+
		Return on investment	Return of Assets (ROA)		+
			Rate of return on investment		+
		Equity ratio index			+
		Full-Time Equivalent (FTE) of manager			+
		Income per student			+
		Lagged commercial revenue			+
		Investment portfolio to total assets			+
		Income from Medicare			-
		Income from Medicaid			-
		Share of temporary restricted net assets			+
		Total assets of the organization			+
		Total sales value			+
		Number of clients or customers			+
		Three-year Cohort Default Rate (TCDR)			-
	Government Grants	The amount of allocated budget to the organization			-
		Government grants			-
		Increase in the share of government grants			+
		Presence of government grants			+
		Amount of government grants			+
	Public Support	Public indirect financial support			Variable
		A combination of the three components (government grants, direct and indirect non-governmental public financial support)			+
	Other	Manager’s budgetary performance			+
		Manager’s tax performance			-
		Relative performance of city managers			-
		Contracted or direct service delivery			Variable (adjusted by the number of covered population)
		Ratio of federal and state grants to total revenue			+
		Endowment or donation to the organization			-
		Payments to affiliates			+
		Contracted managed hospitals			-
Organizational and Intra-organizational Components	Organization Size and Complexity	Size			+
			Number of employees		+
			Number of acute hospital beds		+
			Multi-sited hospital		-
			Total assets annually		+
		Total deferred fixed assets			+
		Total assets			+
		Total expenses			+
		Number of employees with income below 50,000$			+
		Number of staffed hospital beds			+
		Number of services per FTE			+
		Income elasticity			+
		Number of income sources for the organization			+
	Organization Type	The ministry of occupation			Variable
		Indirect administration (an organization with non-governmental ownership but with a governmental function)			+
		System affiliation (manager is politically, socially, etc. linked to different institutions)			+
		Educational reference hospital compared to only educational			+
		Educational hospital			-
		Hospital affiliated to academia			-
	Colleague Managers’ Compensation	Income level of the highest-paid employees in the organization			+
		Average salary for assistant professors of all disciplines in a university			+
	Other	Result-based evaluation of performance mechanism			+
		History of promotion within the organization compared to hiring a manager from outside			+
		Difficulty of work (the number of sites under the manager’s supervision)			+
		U.S. News & World Report college rankings of universities			+
		Carnegie Classification of universities ranking			+
		Other international university ranking systems			+ (for women)
		The number of university entries			+
Environmental and Extra-organizational Factors	Location of Organization	Hospital located in the city			+
		University density			+
	Average Income of the Residence Site	Per capita income of the manager’s place of residence			+
	Rival Managers’ Compensation	Representativeness			Variable
		Alimentation
		Market
		Average annual income of parliament members			+
	Legislative Requirements	Legal ceiling for managers’ remuneration			+
	Other	City’s population size			+
		Percentage of African- Americans in the city			+
		CEO’s income level			+ (on total income)
		Type of industry			Variable
		Private donors			-
		Ideology (Christianity religious beliefs)			-
		Kaufman’s indicator “Voice and Accountability”			-
		Kaufman’s indicator “Rule of Law”			-
		Kaufman’s indicator “Control Corruption”			-
		The Efficacy of Government		Government Effectiveness	-
				Regulatory Quality	-
Personality and Demographic Characteristics	Gender	Gender (Male manager)			+ (4 studies) - (1 study)
	Experience	Years manager has worked in the same organization			+
		Seniority			+
		Number of previous positions			+
		City population (over 50000)			Variable (Conditioning role in the relation)
	Education	MD than non-medical education			+
		Duration of education (years)			+
		Level of education (years)			+
		Holding an MBA degree			+
	Other	Managerial responsibility			+
		Managerial level			+
		Caucasian (White skin) race			-
		Performance-based payment scheme for managers			+
		Age			+
Executive Board	Functional Characteristics	Transparency in the role and duties of board members			+
		Recognized ultimate supervisor of payments			+
		Reasonable performance standards			+
		Independence of board members			+
		Rapid payment monitoring processes			+
	Board Size	Number of paid directors			-
		Number of unpaid directors			-
	Board Structure	Total number of managers (non-senior) present on the board			+
		Number of internal managers (percentage of the board)			+
		Number of directors outside the organization with political ties (percentage of the board)			+
		Number of external directors appointed by the CEO on the board (percentage of the board)			+
		Years that the CEO was active as a board member			+
Politics	Politics	Exogenous termination risk			+
		Political motives in appointing government managers			Variable
		Political sensitivity			+
		Political networking			+
		Institutional pressure			-
Quality	Quality	Quality of staff performance			Variable
		No. of patients recommending hospital services to others			+

Funding Statement

Nil.